Gastric Cancer

Dorsal Track Control (DTC): A Modified Surgical Technique for Atraumatic Handling of the Distal Esophagus in Esophagojejunostomy

Surgical therapy for adenocarcinoma of the esophagogastric junction II requires distal esophagectomy, in which a transhiatal management of the lower esophagus is critical. The ‘dorsal track control’ (DTC) maneuver presented here facilitates the atraumatic handling of the distal esophagus, in preparation for a circular-stapled esophagojejunostomy. It is based on a ventral semicircular incision in the distal esophagus, with an intact dorsal wall for traction control of the esophagus. The maneuver facilitates the proper placement of the purse-string suture, up to its tying (around the anvil), thus minimizing the manipulation of the remaining esophagus. Furthermore, the dorsally-exposed inner wall surface of the ventrally-opened esophagus serves as a guiding chute that eases anvil insertion into the esophageal lumen. We performed this novel technique in 21 cases, enabling a safe anastomosis up to 10 cm proximal to the Z-line. No anastomotic insufficiency was observed. The DTC technique improves high transhiatal esophagojejunostomy.

How could we identify the 'old' patient in gastric cancer surgery? A single centre cohort study

PURPOSE

To analyze the population submitted to gastric cancer surgery in our Institution in order to find those characteristics which could help in the identification of the elderly high-risk patient.

METHODS

In a cohort of 263 patients (>65 y) we selectively investigated the risk factors for medical and surgical complications and postoperative mortality, focusing on the variable "age". All the significant variables were used to find predictors of complications with Clavien-Dindo>2.

RESULTS

Age>75 (AUC 0.61; 95% 0.55-0.67, p = 0.003) and ASA score >2 (AUC 0.60; 95% CI 0.54-0.67, p = 0.01) were significantly associated with an increased risk of medical complications. Operative time >330 min (OR 1.00; 95% CI 1.00-1.01; p = 0.0001- AUC 0.62, 95% CI 0.56-0.68, p = 0.01) was the only significant predictor of surgical complications. In-hospital mortality (6/263 patients) was significantly associated with preoperative albumin ≤2.95 g/dl (OR 0.15; 95% CI 0.04-0.93, p = 0.041 - AUC 0.74 95% CI 0.68-0.80; p = 0.003) and additional procedures (OR 7.05; 1.23-40.32, p = 0.03). Stepwise multivariate analysis showed that albumin ≤2.95 g/dl (OR 3.43; 95% CI 1.06-11.13 p = 0.033), ASA>2 (OR 9.51; 95% CI 1.23-72.97; p = 0.042) and additional resections (OR 3.39; 95% CI 1.36-8.45; p = 0.045) were independent risk factors for complications Clavien Dindo >2.

CONCLUSIONS

Our work demonstrated that, in our institution, 75 years of age could identify the elderly in gastric surgery as those patients were at higher risk of medical complications. ASA >2, preoperative serum albumin ≤2.95 g/dl and the need of additional procedures could increase the risk of severe postoperative adverse events.

Gastric adenocarcinoma surgery and adjuvant therapy

Gastric adenocarcinoma is one of the most common causes of death worldwide. Surgical resection remains the mainstay of therapy, offering the only chance for complete cure. Resection is based on the principles of obtaining adequate margins, with the extent of lymphadenectomy remaining controversial. Neoadjuvant and adjuvant therapies are used to reduce local recurrence and improve long-term survival. This article reviews the literature and provides a summary of surgical management options and neoadjuvant/adjuvant therapies for gastric adenocarcinoma.

Cohort study based on the seventh edition of the TNM classification for gastric cancer: proposal of a new staging system

PURPOSE

We investigated the effect of the new TNM classification on gastric cancer staging.

PATIENTS AND METHODS

From hospital records, information from patients with gastric cancer, who had undergone either total or partial gastrectomy for adenocarcinomas of the stomach or esophagogastric junction, was retrieved. The pathologic TNM stage was determined according to the sixth and seventh editions of the International Union Against Cancer guidelines and was based on surgical pathologic examination.

RESULTS

Five hundred fifty-four patients (338 men and 216 women; median age, 68 years) had undergone partial or complete gastrectomy for intestinal (n = 209) or diffuse (n = 249) adenocarcinoma of the esophagogastric junction and stomach. Survival data and date of death were available for all patients. Patient death correlated significantly with age at diagnosis, tumor type, histologic grade, local tumor growth (T category), number of metastatic lymph nodes, lymph node ratio, lymph node status (N category), and tumor stage. No major difference was noted between the sixth and seventh editions of the TNM classification. On the basis of survival data, we revised the stage grouping system; stage I and II tumors were confined to nonmetastatic tumors, and stage III and IV tumors were confined to metastatic tumors. The Kaplan-Meier plots of this modified stage grouping showed statistically significant differences between individual stage subgroups without crossing curves and demonstrated improved survival of patients with stage II disease.

CONCLUSION

The seventh edition of the TNM classification is associated with a stage migration in 60% of patients with esophagogastric and stomach cancer. This change did not improve the assessment of patient prognosis, and therefore, a revised staging system is proposed.

R0 resection in the treatment of gastric cancer: Room for improvement

Gastric carcinoma is one of the most frequent malignancies in the world and its clinical behavior especially depends on the metastatic potential of the tumor. In particular, lymphatic metastasis is one of the main predictors of tumor recurrence and survival, and current pathological staging systems reflect the concept that lymphatic spread is the most relevant prognostic factor in patients undergoing curative resection. This is compounded by the observation that two-thirds of gastric cancer in the Western world presents at an advanced stage, with lymph node metastasis at diagnosis. All current therapeutic efforts in gastric cancer are directed toward individualization of therapeutic protocols, tailoring the extent of resection and the administration of preoperative and postoperative treatment. The goals of all these strategies are to improve prognosis towards the achievement of a curative resection (R0 resection) with minimal morbidity and mortality, and better postoperative quality of life.

Linfadenectomia ampliada (D2) no tratamento do carcinoma gástrico: análise das complicações pós-operatórias

OBJETIVO: Descrever e analisar as principais complicações pós-operatórias e mortalidade dos pacientes submetidos à ressecção gástrica por câncer gástrico com linfadenectomia D2. MÉTODO: Foi realizada uma coorte histórica onde as principais variáveis em estudo foram: idade, localização do tumor, estadiamento, complicações do procedimento cirúrgico, padrão de recidiva tumoral, análise da sobrevida livre de doença e sobrevida total. RESULTADOS: Foram avaliados 35 pacientes submetidos à dissecção linfonodal D2 no período de Janeiro de 2000 a Dezembro de 2004. A média de idade foi 57 anos. Apenas um (2,9%) paciente apresentava tumor precoce e o local mais comum do tumor foi no terço médio do estômago. O número de linfonodos ressecados por paciente variou de 15 a 80 linfonodos (média 28,8). Vinte e seis (74,3%) pacientes apresentaram linfonodos metastáticos, sendo a média de 13,4 (±11,8) linfonodos comprometidos por paciente. Seis (17,1%) pacientes apresentaram complicações no período pós-operatório, sendo duas pneumonias, uma fístula pancreática, uma fístula do coto duodenal e duas deiscências da anastomose esôfago-jejunal. Apenas um (2,86%) paciente morreu devido a complicações operatórias. O tempo de seguimento médio foi de 26 meses. Vinte e dois pacientes apresentavam-se vivos no fechamento do estudo, com uma sobrevida atuarial de 62,9%. CONCLUSÃO: Os resultados deste estudo sugerem que, em centros especializados, a linfadenectomia D2 é um procedimento com nível de complicações aceitável e pode ser realizada sem aumento da mortalidade operatória.

Prognostic factors in the surgical treatment of gastric cancer--10 years experience

BACKGROUND

In spite of the increase in radicality and extended resections, the prognosis of gastric cancer is very poor. Surgical resection is the only effective therapy. The morbidity and mortality of surgical interventions decreased during the last years.

METHOD

The aim of this study was to evaluate the prognostic effect of different factors on survival of gastric cancer. A retrospective study of 483 patients with gastric cancer was performed. Data were collected from January 1993 to December 2002. There were 380 resections, 267 (70,2%) total gastrectomies, 93 (24.8%) distal resections and 20 (5.2%) proximal resections. Epidemiological factors, tumour and treatment related parameters were analysed. Kaplan-Meier method was used to assess survival and Cox regression analysis to evaluate the effect of prognostic factors on survival.

RESULTS

The rate of R0 resections was 73.4% for total gastrectomy, and 73% for distal gastrectomy. The five-year overall survival of the entire population was 26.08%, 36.2% of the resected patients and 69.05% of curative resections. In concordance with literature findings, radicality of resection, depth of tumour invasion and lymph node metastases proved to be the most powerful independent prognostic factors.

CONCLUSION

Prognosis of gastric cancer can be remarkably improved by a complete resection of the tumour and its lymphatic drainage, even if extension of the resection is needed.

Adenocarcinoma of the esophago-gastric junction

BACKGROUND

The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification.

METHODS

In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations.

RESULTS

The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.

Adenocarcinoma of the esophagogastric junction: surgical therapy based on 1602 consecutive resected patients

Because of the borderline location between the esophagus and stomach, many discrepancies exist in the current literature regarding the etiology, classification, and surgical treatment of adenocarcinoma arising at the esophagogastric junction. The classification of adenocarcinomas into three types, AGE type I, type II, and type III, shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are recommended for a good, long-term prognosis. With better surgical management and standardized procedures, even the results in patients with more radical surgical approaches, the abdomino-thoracic esophagectomy improved.

Adenocarcinoma of the Esophagogastric Junction in China according to Siewert's classification

BACKGROUND

There had never been a clear definition of the cancer of cardia before Siewert's classification, which was proposed in 1996 and approved in 1997 at the second International Gastric Cancer Congress in Munich. On the basis of the classification, this study aims to research into the clinicopathological characteristics and surgical modes of adenocarcinoma of the esophagogastric junction in China.

METHODS

The study reviewed the data of the distal esophageal cancer, the cancer of cardia and the proximal gastric cancer at the First Hospital of Xi'an Jiaotong University from January 1995 to December 1999. Surgical patients were defined and classified according to Siewert's classification, and 203 patients were up to the classification. Then the study compared and analyzed the clinicopathological characteristics and the survival rates of the three types of the tumor.

RESULTS

Among the 203 patients, there were 29 patients with adenocarcinoma of the distal esophagus (Type I); 80 patients with true carcinoma of cardia (Type II); and 94 patients with subcardial carcinoma (Type III). Obvious differences were found in the clinicopathological characteristics of the three types, but no significant difference of the 5-year survival rates was found among the three types of patients with curative resection.

CONCLUSION

On the data, the distribution of the three types of tumor was found to be different from that reported in Western countries and in Japan; and the three types of patients who had undergone curative resection were found to have similar 5-year survival rates.

Prognostic score in gastric cancer: the importance of a conjoint analysis of clinical, pathologic, and therapeutic factors

BACKGROUND

This study was designed to establish a prognostic score for gastric cancer that takes into account factors related to the tumor, the patient, and the treatment.

METHODS

Two hundred thirty patients with gastric adenocarcinoma admitted t o the Department of Abdominal Surgery at Hospital do Câncer A. C. Camargo (São Paulo) and treated by gastrectomy from January 1992 until December 1996 were included in this retrospective cohort. The prognostic score was created according to the variables identified in the multivariate analysis and by using the regression coefficients generated by the Cox regression.

RESULTS

The 5-year overall survival rate was 44.5%. The final multivariate model identified six variables with a significant and independent effect on survival: sex, weight loss, lymphocyte count, tumor-node-metastasis staging, lymphadenectomy, and lymph node ratio. Patients were divided into four groups according to their scores, as follows: group 1, 0 to 3.0; group 2, 3.5 to 5.5; group 3, 6.0 to 8.5; and group 4, 9.0 to 14.0. The 5-year survival rates were 91.5%, 49.3%, 20.3%, and .0% for the score groups 1, 2, 3, and 4, respectively (P<.001). The score was superior in the assessment of prognosis when compared with tumor-node-metastasis staging alone.

CONCLUSIONS

It is possible to create a prognostic score that simultaneously includes factors related to the tumor, patient, and treatment, thus generating a more effective system in predicting the prognosis than the morphology-based staging systems.

The role of chemotherapy in patients with established gastric cancer

Chemotherapy significantly improves survival in comparison to best supportive care in patients with metastasised gastric cancer. In patients for whom a three-drug-combination is considered as the treatment of choice, ECF (epirubicin, cisplatin and 5-FU as a continuous infusion) should be regarded as standard of care. However, results for ECF have been challenged by the recently presented REAL-2-trial, which demonstrated a significant survival benefit for EOX (epirubicin, oxaliplatin, capecitabine) over ECF. Adjuvant 5-FU-based chemoradiation should be discussed in patients with inadequate lymphadenectomy, but is not internationally accepted as standard of care: whether patients with adequate lymhphadenectomy benefit from adjuvant chemoradiotherapy is currently unclear. According to the results of the UK MAGIC trial, perioperative treatment with ECF (3 cycles prior to and post surgery) results in a significantly reduced risk of death for patients with resectable gastric cancer as compared to surgery alone. Neo-adjuvant chemotherapy has the ability to downsize gastric tumours and appears to improve R0-resection rates, but its potential to improve overall survival is still unclear.

Radical gastrectomy for cancer of the stomach

Carcinoma of the stomach remains one of the most common causes of cancer deaths in the world. The only treatment to offer hope for cure or long-term palliation is surgery. Optimal surgical resection requires an adequate margin of normal tissue around the tumor,dissection of perigastric lymph nodes, and en-bloc removal of organs involved by direct extension. Extended lymphadenectomy has not been shown to offer survival advantage in the West.

Prognostic indicators in locally advanced gastric cancer (LAGC) treated with preoperative chemotherapy and D2-gastrectomy

BACKGROUND AND OBJECTIVES

Neoadjuvant chemotherapy is increasingly considered an effective treatment option for patients with gastric carcinoma. Aim of the study is to evaluate the prognostic significance of the pathological response and of known prognostic factors in a group of accurately staged locally advanced gastric cancer (LAGC) patients.

METHODS

Thirty-three patients with LAGC, staged by laparoscopy, underwent D2-gastrectomy after preoperative chemotherapy. Survival was calculated by Kaplan-Meier method and differences were assessed by the Log-rank and Breslow test. Multivariate analysis was performed using the Cox proportional hazard model in backward stepwise regression.

RESULTS

Curative resection (R0) was achieved in 81.8% of patients. A complete or subtotal pathological response was documented in 3 and 6%, respectively. Nineteen out of thirty-three (57.6%) patients were alive and 16 of them were free of relapse at last follow-up. Survival rates were 81, 67, and 59% at 12, 24, and 36 months, respectively. At univariate and multivariate analysis, only R0 resection was found to be an independent prognostic factor.

CONCLUSIONS

In the current study, R0 resection is the most important prognostic factor for resectable LAGC; according to our results we feel encouraged to consider neoadjuvant chemotherapy a promising modality for increasing the R0-percentage of gastric carcinoma patients who could benefit from a curative surgery.

Gastrectomia em pacientes idosos: análise dos fatores relacionados a complicações e mortalidade

OBJETIVO: Verificar as variáveis que influenciam os resultados pós-operatórios no tratamento do adenocarcinoma gástrico em pacientes idosos. MÉTODO: Foi realizada uma coorte histórica onde as principais variáveis em estudo foram: idade, localização do tumor, estadiamento, doenças associadas, complicações do procedimento cirúrgico e mortalidade operatória. Os pacientes foram separados em dois grupos em relação à idade [Grupo I (< 65 anos) e Grupo II ( 65 anos)], de maneira que os fatores associados com maior mortalidade fossem analisados de forma independente. RESULTADOS: Foram avaliados 160 pacientes submetidos à ressecção gástrica. A média de idade foi 60,7 anos. Presença de doenças associadas, classificação ASA III ou IV e mortalidade operatória foram associados com indivíduos mais velhos. Não houve diferença entre os grupos em relação à localização do tumor no estômago, ressecção empregada, estágio dos tumores e complicações pós-operatórias. A mortalidade operatória foi 6,1% no Grupo I e 12,9% no Grupo II. O principal fator de risco para o óbito na análise univariada foi a presença de doenças associadas (p<0,03). Na análise multivariada, o único fator de risco significativo para maior mortalidade foi classificação ASA mais avançada. CONCLUSÃO: Os idosos operados por adenocarcinoma gástrico apresentam fator de risco mais acentuado de morte pós-operatória. Contudo, a idade cronológica não pode ser definida como um fator determinante, e sim circunstâncias de doenças associadas e condições fisiológicas que os acompanham nessa faixa etária.

Neoadjuvant therapy for oesophagogastric cancer

BACKGROUND

The prognosis after surgery for oesophagogastric cancer remains poor.

METHODS

This review clarifies current indications for neoadjuvant therapy for oesophageal and gastric cancer. A systematic literature research and evaluation of data from international cancer meetings were carried out.

RESULTS

Recently published results of large randomized phase III trials underscore the potential value of neoadjuvant treatment for oesophagogastric cancer. However, it remains uncertain which subgroups of patients should routinely undergo preoperative therapy. Metabolic response evaluation during neoadjuvant treatment is a promising tool for the selection of responding patients.

CONCLUSION

Neoadjuvant chemotherapy is a valid option for locally advanced oesophageal and gastric cancer. In the future, more effective and better tolerated treatment strategies, tailored to the specific tumour characteristics of each individual, should be possible.

Comparison of complications after D2 and D3 dissection for gastric cancer

BACKGROUND

D3 dissection is accepted as having higher rates of mortality and morbidity than D2 dissection. In this study, we aimed to evaluate the mortality and morbidity rates of D3 dissection in our department and to compare these with mortality and morbidity after D2 dissection.

PATIENTS AND METHODS

All patients who underwent radical gastric resection with lymph node dissection for gastric adenocarcinoma between June 1999 and June 2002 were evaluated. Clinicopathologic features of the tumour, the resection and lymphadenectomy, the postoperative mortality and morbidity were analysed.

RESULTS

There were 359 patients admitted for the treatment of gastric cancer. One hundred twenty four underwent palliative resection and 134 underwent resection with curative intent. Of 34/134 patients, underwent gastric resection with D3 dissection, and 100 underwent D2 dissection. The overall operative mortality rate of D2 and D3 dissections was 1 and 8.8%, respectively (p<0.05). The relaparotomy rate was almost doubled in D3 dissection group (11.8% vs. 6%) but this difference was not statistically significant. D3 dissection was also associated with an increase in morbidity (35.3% vs. 10%, p<0.05).

CONCLUSIONS

This study indicates that D3 dissection can be performed with reasonable safety. It may be a useful alternative procedure in advanced cases for which additional risks of surgical morbidity and mortality are felt to be outweighed by potential benefits to patients.

Complications of gastrectomy following CPT-11-based neoadjuvant chemotherapy for gastric cancer

Potential benefits of neoadjuvant therapy for locally advanced gastric cancer include tumor downstaging and an increased R0 resection rate. Potential disadvantages include increased surgical complications. This study assesses postoperative morbidity and mortality by comparing patients undergoing gastrectomy with and without neoadjuvant chemotherapy. From October 1998 to July 2002, a total of 34 patients with locally advanced gastric cancer were placed on a phase II neoadjuvant chemotherapy protocol consisting of two cycles of CPT-11 (75 mg/m(2)) with cisplatin (25 mg/m(2)). Demographic, clinical, morbidity, and mortality data were compared for these patients (CHEMO) versus 85 patients undergoing gastrectomy without neoadjuvant chemotherapy (SURG). The CHEMO patients were more likely to be less than 70 years of age (P< or =0.01), have proximal tumors (P< or =0.01), and undergo proximal gastrectomy (P< or =0.025). Fifty-two percent of SURG patients had T3/T4 tumors compared to 19% of CHEMO patients, consistent with tumor downstaging. The R0 resection rate was similar (80%). Morbidity was 41% in CHEMO patients and 39% in SURG patients. There were five postoperative deaths (4.4%), two in the CHEMO group and three in the SURG group (P=NS). It was concluded that neoadjuvant chemotherapy with CPT-11 and cisplatin is not associated with increased postoperative morbidity compared to surgery alone. CPT-11-based neoadjuvant chemotherapy should be tested further in combined-modality treatment of gastric cancer.

Surgical management of and long-term survival after adenocarcinoma of the cardia

BACKGROUND

The choice of surgical strategy for patients with adenocarcinoma of the oesophagogastric junction is controversial. This study was performed to analyse the surgical results of a 20-year experience with these lesions.

METHODS

From January 1981 to January 2001, 126 patients with adenocarcinoma of the cardia underwent resection in the authors' institution. The treatment of choice was oesophagectomy for type I tumours, and extended gastrectomy for type II and III lesions. Morbidity, mortality and survival were determined retrospectively.

RESULTS

Fifty-six patients (44.4 per cent) had type I tumours, 44 (34.9 per cent) type II and 26 (20.6 per cent) type III. Primary resection was performed in 113 patients (89.7 per cent). Oesophagectomy with resection of the proximal stomach was carried out in 65 patients (51.6 per cent) and extended total gastrectomy with transhiatal resection of the distal oesophagus in 61 (48.4 per cent). In-hospital mortality and morbidity rates were 4.8 and 34.1 per cent respectively. The overall 3- and 5-year survival rates were 40.9 and 25.1 per cent respectively, and were not affected by the surgical approach. Survival was significantly associated with R0 resection, pathological node-positive category, postoperative complications and tumour differentiation.

CONCLUSION

Postoperative mortality, morbidity and long-term survival did not appear to be affected by surgical approach. Further prospective studies are needed to confirm the equivalence between transthoracic and transabdominal approaches.

Treatment of advanced gastric cancer by palliative gastrectomy, cytoreductive therapy and postoperative intraperitoneal chemotherapy

BACKGROUND

The treatment options for the 10-20 per cent of patients with gastric cancer who present with peritoneal dissemination are extremely limited and no standard approach exists.

METHODS

The feasibility of using intraperitoneal chemotherapy to treat gastric cancer with intra-abdominal gross residual lesions after palliative gastrectomy with maximal cytoreduction was investigated. Early postoperative intraperitoneal chemotherapy started on the day of operation with 5-fluorouracil 500 mg/m2 and cisplatin 40 mg/m2 (days 1-3) over a 4-week interval.

RESULTS

Of the 53 patients enrolled between July 1994 and December 1998, 49 were eligible. The progression-free survival (PFS) was 7 months and the overall survival was 12 months. In multivariate analysis, performance status was the only significant defining factor for PFS (P = 0.009). The predominant toxicity was neutropenia and nausea/vomiting. The relative dose intensity of 5-fluorouracil and cisplatin was 89 and 63 per cent respectively.

CONCLUSION

Performance status emerged as a major determining factor for prognosis and patient selection for early postoperative intraperitoneal chemotherapy in patients with advanced gastric cancer after maximally cytoreductive surgery.

Site-dependent resection techniques for gastric cancer

In addition to tumor stage and growth pattern, the tumor site is a major factor in determining the extent of resection and lymphadenectomy necessary in patients with gastric carcinoma. Total gastrectomy with D2-lymphadenectomy is the procedure of choice for tumors of the gastric corpus. Extended total gastrectomy with trans-hiatal resection of the distal esophagus is required for tumors of the proximal region; in these patients lymphadenectomy may also include splenic hilum and left retroperitoneal nodes. In patients with distal gastric carcinoma, a subtotal gastrectomy often achieves a complete tumor resection. Extended lymphadenectomy in these patients includes the retroduodenal and right para-aortic nodes in addition to a D2-dissection. In patients with early tumor stages, anatomically oriented limited resection techniques are increasingly important. The concept of the sentinel lymph node may result in more selective lymphadenectomy strategies in the near future [15]. For patients with a locally advanced disease, these surgical concepts must be evaluated within multimodal treatment protocols [16].

D3 lymph node dissection in gastric cancer: evaluation of postoperative mortality and complications

Since November 1995 we have been performing a D3 lymph node dissection in patients undergoing an operation for gastric cancer with a curative intent. The aim of the present study was to evaluate whether this procedure results in an increased postoperative mortality or complication rate in a Western population. Between November 1995 and August 1997 the postoperative courses of 76 patients were retrospectively assessed (45.3 lymph nodes per patient, lymph node ratio: 0.16). The patient outcome was compared with data from a historic control group of patients (n = 383) in whom the newly established D2 dissection was studied in our department. Regarding the demographic, clinical, and tumor-pathologic data, and the choice of resection and reconstructive procedures, the two groups differed only slightly. The postoperative mortality of 1% was lower (vs 6.8%) while the overall complication rate of 34% (vs 32.1%) was identical. In particular, no anastomotic leakage (vs 9.4%) and fewer nonsurgical complications (17.1% vs 27.9%) occurred. The reoperation rate was 1% vs 9.7%. However, in 6% of the patients drainage tubes had to be inserted under computed tomographic guidance. The average hospital stay remained unchanged (21.9 vs 20.7 days). A D3 dissection was shown to be feasible while demonstrating no disadvantages in the patients when compared with the D2 procedure.

Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients

OBJECTIVE

To assess the outcome of surgical therapy based on a topographic/anatomical classification of adenocarcinoma of the esophagogastric junction.

SUMMARY BACKGROUND DATA

Because of its borderline location between the stomach and esophagus, the choice of surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial.

METHODS

In a large single-center series of 1,002 consecutive patients with adenocarcinoma of the esophagogastric junction, the choice of surgical approach was based on the location of the tumor center or tumor mass. Treatment of choice was esophagectomy for type I tumors (adenocarcinoma of the distal esophagus) and extended gastrectomy for type II tumors (true carcinoma of the cardia) and type III tumors (subcardial gastric cancer infiltrating the distal esophagus). Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor types, focusing on the pattern of lymphatic spread, the outcome of surgery, and prognostic factors in patients with type II tumors.

RESULTS

There were marked differences in sex distribution, associated intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, and stage distribution between the three tumor types. The postoperative death rate was higher after esophagectomy than extended total gastrectomy. On multivariate analysis, a complete tumor resection (R0 resection) and the lymph node status (pN0) were the dominating independent prognostic factors for the entire patient population and in the three tumor types, irrespective of the surgical approach. In patients with type II tumors, the pattern of lymphatic spread was primarily directed toward the paracardial, lesser curvature, and left gastric artery nodes; esophagectomy offered no survival benefit over extended gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophagogastric junction into type I, II, and III tumors shows marked differences between the tumor types and provides a useful tool for selecting the surgical approach. For patients with type II tumors, esophagectomy offers no advantage over extended gastrectomy if a complete tumor resection can be achieved.

A prognostic score for gastric cancer

BACKGROUND

Scoring systems are generally used for predicting prognosis in the intensive care unit, but there is no score being used frequently for predicting prognosis in gastric cancer. The aim of this study was to develop a prognostic score for gastric cancer patients.

METHODS

Demographic, clinical, laboratory, radiologic, histopathologic data, and operative findings for 128 patients who had curative or palliative resection for gastric cancer were analyzed for their effect on overall and disease-free survival. Ten variables-invasion depth of tumor, node status (American Joint Committed on Cancer, 1992), metastasis, node status (Union Internationale Contre le Cancer, 1997), metastatic lymph node ratio, resectability, tumor location, extent of lymphadenectomy, Borrmann type, Lauren type-that have independent significant effect or borderline significance on both overall and disease-free survival according to multivariate analysis were chosen. Coefficients were calculated for these variables by using Cox regression analysis, and thus the Prognostic Score for Gastric Cancer (PSGC) was designed. All patients were scored using the PSGC and also staged clinically (AJCC 1992) and histopathologically (AJCC 1992 and UICC 1997).

RESULTS

Patients were grouped according to their scores: group 1, patients with scores 20 to 50 (probability of 5-year overall survival 50% to 95%); group 2, patients with scores 51 to 80 (probability of 5-year overall survival 10% to 50%); and group 3, patients with scores 81 and higher (probability of 5-year overall survival <10%). Overall survival and disease-free survival decreased significantly with increasing scores. The association of PSGC and staging systems with survival was analyzed by stepwise logistic regression and Cox regression analyses. PSGC was proved to have the most significant association with overall and disease-free survival.

CONCLUSIONS

Inclusion of more variables in PSGC seems to make it superior than staging. It is easy to adapt PSGC to different patient populations, which may make it accepted as a practical and useful scoring system in clinical practice.

Multidisciplinary approach to esophageal and gastric cancer

Despite marked advances in surgical therapy for patients with esophageal, esophagogastric, and gastric cancers, the overall prognosis of these patients has not markedly improved during the past decades. Multidisciplinary approaches using adjuvant postoperative and neoadjuvant preoperative therapeutic principles have received increasing attention with regard to the management of these patients. A series of randomized, prospective trials has demonstrated that adjuvant postoperative radiation or chemotherapy does not result in a convincing survival advantage after complete tumor resection in esophageal, esophagogastric junction, or gastric cancer. The available data on the role of neoadjuvant preoperative therapy are not yet conclusive. Although neoadjuvant therapy may reduce the tumor mass in many patients, several randomized, controlled trials have shown that, compared with primary resection, a multimodal approach does not result in a survival benefit in patients with locoregional, that is, potentially resectable, tumors. In contrast, in patients with locally advanced tumors, that is, patients in whom complete tumor removal with primary surgery seems unlikely, neoadjuvant therapy increases the likelihood of complete tumor resection on subsequent surgery, but only patients with objective histopathologic response to preoperative therapy seem to benefit from this approach. Consequently, in the future, improvements in the overall survival of patients with esophageal, esophagogastric junction, or gastric cancer most likely will be achieved only by tailored therapeutic strategies that are based on the individual tumor location, tumor stage, and consideration of established prognostic factors. A clear classification of the underlying tumor entity, a profound knowledge of the prognostic factors applicable, a thorough preoperative staging, and identification of parameters that allow for the prediction of response to preoperative therapy will become essential for the selection of the optimal therapeutic modality for individual patients.

Surgical resection for cancer of the cardia

From the pathogenic and therapeutic point of view, adenocarcinomas of the esophagogastric junction (AEG) should be classified into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II), and subcardial carcinoma (Type III). This classification can be easily performed by summarizing the information available from contrast radiography, endoscopy, and intra-operative findings; it allows comparison of data between various centers and facilitates the choice of surgical therapy. A complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the esophagogastric junction. In patients with potentially resectable, true carcinoma of the cardia (AEG Type II), this can be achieved by a total gastrectomy with transhiatal resection of the distal esophagus and en bloc removal of the lymphatic drainage in the lower posterior mediastinum and along the celiac axis and superior border of the pancreas. This approach is associated with lower morbidity and provides equal long-term survival as compared to the more radical transmediastinal or abdominothoracic esophagogastrectomy. Whether a routine splenectomy for lymphadenectomy in the splenic hilus offers a survival benefit in these patients is questionable. In patients with early tumors staged as uT1 on pre-operative endosonography, a limited resection of the proximal stomach, cardia, and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment appears justified since this procedure allows a complete tumor removal with adequate lymphadenctomy and offers excellent functional results. Multimodal therapy with pre-operative polychemotherapy or combined radio-chemotherapy appears to offer a significant survival benefit in patients with locally advanced tumors. With this tailored approach, extensive pre-operative staging becomes mandatory for an adequate selection of the appropriate therapeutic concept.

Neoadjuvant chemotherapy for patients with locally advanced gastric carcinoma: effect on tumor cell microinvolvement of regional lymph nodes

BACKGROUND

In a previous study the authors demonstrated, using immunohistochemical methods for epithelial antigens, that the regional lymph nodes of gastric adenocarcinoma contained individual tumor cells or small clusters of these cells (tumor cell microinvolvement [TCM]) in over 90% of cases. In the current study the authors used the same method to investigate a series of gastric adenocarcinoma cases treated with neoadjuvant chemotherapy prior to tumor resection; their aim was to determine the effect of chemotherapy on TCM in regional lymph nodes.

METHODS

Resection specimens from 17 patients with adenocarcinoma of the stomach, resected after neoadjuvant treatment and classified by routine histology as ypN0, were included in this study. One section from each of the 622 lymph nodes dissected from these specimens was stained by immunohistochemical methods for cytokeratins and Ber-Ep4.

RESULTS

Six patients (35%) and 25 of the 622 lymph nodes (4.0%) had TCM, compared with 93% of patients and 21.8% of lymph nodes in the previous study of patients treated with surgery alone. The lymph node response to chemotherapy correlated with the pathologic response of the primary tumor. Specifically, none of 5 patients with a complete or major pathologic response versus 6 of 12 (50%) patients with minor, partial, or no response had lymph node microinvolvement.

CONCLUSIONS

In comparison to our previous study, this study indicates that chemotherapy has a marked effect on tumor cells in regional lymph nodes and that the extent of this effect can be correlated with the degree of pathologic response of the primary tumor to chemotherapy.

Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study

OBJECTIVE

In 1986 a prospective multicenter observation trial in patients with resected gastric cancer was initiated in Germany. An analysis of prognostic factors based on the 10-year survival data is now presented.

PATIENTS AND METHODS

A total of 1654 patients treated for gastric cancer between 1986 and 1989 at 19 centers in Germany and Austria were included. The resected specimen were evaluated histopathologically according to a standardized protocol. The extent of lymphadenectomy was classified after surgery based on the number of removed lymph nodes on histopathologic assessment (25 or fewer removed nodes, D1 or standard lymphadenectomy; >25 removed nodes, D2 or extended lymphadenectomy). Endpoint of the study was death. Follow-up is complete for 97% of the included patients (median follow-up of the surviving patients is 8.4 years). Prognostic factors were assessed by multivariate analysis.

RESULTS

A complete macroscopic and microscopic tumor resection (R0 resection according to the UICC 1997) could be achieved in 1182 of the 1654 patients (71.5%). The calculated 10-year survival rate in the entire patient population was 26.3% +/- 4.7%; it was 36.1% +/- 1.6% after an R0 resection. In the total patient population there was an independent prognostic effect of the ratio between invaded and removed lymph nodes, the residual tumor (R) category, the pT category, the presence of postsurgical complications, and the presence of distant metastases. Multivariate analysis in the subgroup of patients who had a UICC R0 resection confirmed the nodal status, the pT category, and the presence of postsurgical complications as the major independent prognostic factors. The extent of lymph node dissection had a significant and independent effect on the 10-year survival rate in patients with stage II tumors. This effect was present in the subgroups with (pT2N1) and without (pT3N0) lymph node metastases on standard histopathologic assessment. The beneficial effect of extended lymph node dissection for stage II tumors persisted when patients with insufficient lymph node dissection (<15 nodes) were excluded from the analysis. There was no difference in the postsurgical morbidity and mortality rates between patients with standard and extended lymph node dissection.

CONCLUSIONS

Lymph node ratio and lymph node status are the most important prognostic factors in patients with resected gastric cancer. In experienced centers, extended lymph node dissection does not increase the mortality or morbidity rate of resection for gastric cancer but markedly improves long-term survival in patients with stage II tumors. This effect appears to be independent of the phenomenon of stage migration.